Managing Health Care Assistants
The Frontier of Control in NHS Modernization and Skill-Mix Strategies?
Ian Clark and Amanda Thompson
Abstract
NHS modernization aims to make hospitals more flexible and modern for patient experience by cheapening the
costs of nursing care and re-allocating these distributive gains internally in the workplace. Based on sixty
interviews and structured questionnaires completed in one NHS Trust this study asks three research questions.
First, how do HCA’s experience modernization where the frontier of control has moved decisively in favour of
management? Second, how do locally contingent approaches to HCA’s and equally contingent resistance
strategies provide organizational context to workplace control regimes? Third, are absence and job satisfaction
understood as resistance strategies which structure antagonism within NHS modernization? Absence appears as
a form of resistance to work intensification and associated management demands but is tolerated because it does
not formally threaten the managerial prerogative. HCA’s retain intrinsic job satisfaction but marginalize aspects
of their role particularly hands-off patient care and secure distributive gains by imposing this loss on those they
seek to help. At the macro level HCA’s retain intrinsic job satisfaction in a contractual approach where they
dissociate use of absence from its effects on patients and colleagues.
Ian Clark, IC70@le.ac.uk
Centre for Sustainable Work and Employment Futures*,
The University of Leicester School of Management,
Fielding Johnson Building,
University Road,
Leicester,
LE1 7RH
Amanda Thompson, athompson@dmu.ac.uk
Head of Department of HRM,
DeMontfort University,
The Gateway,
Leicester,
LE1 9BH.
*The Centre for Sustainable Work and Employment Futures is funded by the Medical Research Council
and the Economic and Social Research Council.
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Introduction
For the past thirty five years Conservative and Labour governments have sought to restructure professionalized bureaucracy models which have sustained clinician dominance in
the National Health Service since its creation in 1948. In the 1980s’ Thatcherite reforms
focussed on, (what is now termed), new public management which aimed to dilute clinician
dominance and introduce a strong performance management culture. Moreover, ‘new’ public
managers were increasingly steered to focus on the rhetoric of patients as customers and
service provision as a quality experience but one in which customer expectations were
managed (see Bolton, 2004 Hartley and Skeltcher, 2008 and Ferlie et. al. 2013). In 1997 New
Labour announced, (what was seen at the time to be), a more strategic approach to workforce
management, (Bach, Kessler and Heron, 2008). This included a ten year NHS investment
plan which tied higher spending to an explicit modernization and reform agenda, (DE, 2000).
Initiatives such as the NHS human resources plan, (2002) and ‘Agenda for Change’
implemented a service wide job evaluation scheme which sought to modernize work practices
and associated pay grading. The combined aim of these reform strategies was to create a
division of labour wherein health care professionals became subject to control by hospital
managers. One innovation which has continued un-interrupted through the Thatcher, Major,
Blair, Brown and Cameron governments is the development, extension and further
development of Health Care Assistants (HCA’s) in NHS hospitals.
An extensive literature has grown to follow the development, role, status and controversies
which surround the HCA role. Recently published official contributions to this literature seek
to clarify the strengths and weaknesses of the HCA role with much of this clarification
prompted by the failures in nursing care at North Staffordshire hospital, (Cavendish, 2013,
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Francis, 2013). This paper contributes to the literature by developing a theoretically informed
empirical conception of how HCA’s experience the macro modernization agenda in a large
teaching and university hospital, (TUH), as both individuals and as a sectional work group.
The paper divides into four parts. Part one outlines what HCA’s are and reviews the literature
on the emergence and use of HCA’s. Part two further divides the core research question on
the work experience of HCA’s under modernization into three component parts. Part three
then outlines the research design, details how the empirical evidence was constructed to
inform a critical case approach and reports the findings from this study. Part four contains a
discussion and conclusion which identifies the contribution of this study in respect of the
research questions outlined in part two.
1, Health Care Assistants and the Literature on Health Care Assistants
1.1 Health Care Assistants
Recruited as unqualified support staff the term HCA describes staff who may work toward
NVQ level two or three in healthcare, however, study for this qualification is not compulsory
or a requirement of the job. HCA’s provide the bulk of hands-on care in hospitals and make
up a third of all caring staff in hospitals. In 2012 there were between 106,500 to 270,000
HCA’s in the UK providing support to doctors and nurses. There are however, over 60 job
titles which may or may not cover HCA’s hence the wide span of possible numbers, (HSCIC,
2012, Cavendish, 2013:6,15). HCA’s undertake nursing duties and direct patient care under
the delegated guidance of registered nurses. HCA work is divided into routine tasks; making
beds, helping patients with bathing and eating, monitoring and recording glucose levels,
taking patient temperature and pulse, weighing patients, checking patient respiration,
managing patient dressings and escorting patients around a hospital. HCA’s can also
undertake more advanced tasks such as catheterisation, cannulisation, complex dressings,
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machine monitoring and responses, injections and taking blood, ECG tracings and care
planning. In addition to these roles HCA’s perform hands-off caring roles previously
associated with nursing auxiliaries such as talking to patients and their relatives and helping
to make them feel better. The Cavendish Report makes it clear that medical advances, the
emergence of a management scheduling culture, an ageing population and the effects of the
EU working time directive may witness HCA’s undertaking invasive procedures – advanced
tasks - which were previously the preserve of doctors and registered nurses. There is no
consistent or compulsory training programme for HCA’s neither is there a nationwide job
description, therefore training, job descriptions and job design are locally contingent. Pay
wise, whilst originally outside the collective bargaining framework, HCA’s are employed on
bands 1-3 in the agenda for change framework whereas band four represents an assistant
practitioner grade. Nationally 56% of HCA’s are paid on band two. Indeed registered nurses
and HCA’s are seen as separate sources of labour and the decision to make nursing an all
degree profession has had three impacts on HCA’s. Firstly, on the role – HCA’s argue they
are overlooked and undervalued. Secondly, on status – HCA’s are lowly paid, unskilled and
unqualified, that is, not professionally qualified to the standard of physiotherapists, registered
nurses and social workers. A third effect of all graduate entry for registered nurses falls on
the labour process of HCA’s, much of which is delegated to them by professionally qualified
staff often on a task-by-task basis.
The development and diffusion of the HCA role poses several challenges to hospital
managers, ward managers, regulators, patients and HCA’s themselves, for example, public
safety and job performance. There is no minimum standard of qualification or any language
requirement for entry to HCA grades neither is there a register of HCA’s. Similarly, for job
performance – the absence of clearly defined job descriptions risk stretching inclusions in
routine and advanced tasks beyond the competence of HCA’s. Here major infection risks
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flow from poor practice in catheterization and complex wound dressing. Despite the
negatives outlined above many HCA’s retain intrinsic job satisfaction whilst recognising that
caring may does not have a vocational career pathway.
1.2 The Literature on Health Care Assistants
In recent years there has been a considerable amount of research undertaken on HCA’s and
more recently important policy work has been published too. To make sense of this extensive
literature the review divides into sub-sections which identify specific issues that the literature
highlights. This will avoid what might amount to one long list of literature, hence
contributors to the literature can appear under more than one heading.
Modernization and Skill Mix
Daykin and Clarke (2000) provide a qualitative study which examines modernization and
skill mix as fordist strategies sponsored by the state and formulated by hospital managers that
aim to de-skill and routinize elements of nursing work. As an internal division of labour the
modernization agenda sees qualified graduate nurses move away from the delivery of care
towards administrative, technical and supervisory roles. Aspects of nursing work became
routinized, that is standardized and de-skilled and in effect delegated to HCA’s. Daykin and
Clark (2000) found that whilst registered nurses held ambivalent attitudes towards
modernization HCA’s saw modernization as an opportunity to develop knowledge and skills
and increase their workplace independence and level of job satisfaction. Moreover, the
attitudes of both groups enabled hospital managers to further diffuse modernization as an
internal division of labour to reduce reliance on agency and bank nurses in favour of HCA’s
and therefore contain costs. Spilsbury and Meyer (2004) provide case study findings on the
changing role of registered nurses and evaluate the impact of this change on the delivery of
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nursing care, that is, the way this has been delegated to HCA’s. The study finds that whilst
HCA’s complement, supplement, replace or substitute for registered nurses HCA work is
confined to direct patient care whereas registered nurses concentrate more on housekeeping,
administrative and scheduling duties. One effect of this strategy is that HCA’s ‘local
knowledge’ of patients is ignored and reflects explicit and implicit efforts towards
occupational closure by registered nurses. One result of closure is that HCA’s spend more
time with patients dispensing routine nursing care than registered nurses, (see Spilsbury and
Meyer, 2004).
NHS modernization in the form of skill-mix strategies re-defines health care professionals as
managers with the effect of dividing health care professionals into competing groups and
creates new roles for ward managers and registered nurses. The focus of modernization is
individual hospitals as workplaces where one lasting effect of skill-mix is the creation of a
division of labour wherein ‘health care professionals’ are now subject to control by hospital
managers rather than clinicians. Within new public management managers increasingly focus
on the rhetoric of business networks and partnerships, patients as customers and service
provision as a quality experience. These roles centre on leadership, empowerment and
delegated support for HCA’s who are increasingly responsible for direct patient care, (see
Bolton 2004, Ferlie, et.al. 2013). More specifically still this division of labour has changed
the role and status of clinicians and hospital workers, for example, charge nurses are now
termed ward managers whereas nurses are now termed graduate or registered nurses. As
Bolton (2005:6-7) observes these changes have the effect of ‘making-up’ managers in the
NHS. Policy wise both the Cavendish report, (2013) on HCA training and development
standards and the Francis report on mid Staffordshire hospital, (2013) identify the limitations
of modernization and skill-mix for HCA’s and patient safety.
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Flexibility and De-Skilling?
The customer-quality-care theme follows from the strategic approach of the New Labour
government to the NHS workforce where flexibility or the intensification of some nursing
auxiliary roles into the HCA’s remit reflects this ambition, (see Dept. Health, 2002). For
example, since 2000 UK health policy has emphasized flexibility in the context of labour
shortages and the performance management requirements of enhanced patient care – ‘the care
as a quality experience for patients as customers theme’, (Dept. of Health, 2000, Bolton 2004,
Bosley and Dale, 2008). Despite this ambition contributors to the literature report that whilst
the promotion of more flexible work practices was, in the abstract rhetoric of change
management, designed to improve employee motivation and job satisfaction, HCA’s may
experience this rather differently. Bach, Kessler and Heron, (2008) identify variability of
experience in the detail of HCA’s roles to highlight competing approaches to and models of
nursing care. More recently Cavendish, (2013:36) referred to these differences directly as the
absence of national standards for training, development and HCA supervision in the delivery
of routine and advanced tasks. Other contributors emphasise how flexibility of this type stems
in part from registered nurses focussing their work time on the management of compliance in
medication its associated paperwork and scheduling, (Hancock and Campbell, 2006, Bosley
and Dale, 2008:119). More specifically Hyde et. al. (2005:704) examine the manner in which
role re-design in the health service degrades nursing care wherein HCA’s substitute for
registered nurses. This theme is also highlighted by Nancarrow and Borthwick (2005) who
report that unskilled, that is unqualified non-graduate, HCA’s now undertake tasks previously
performed by registered nurses. This evidence base also demonstrates that the work activity
of many registered nurses is focussed beyond direct care, in routine and even advanced tasks.
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In turn this focus beyond nursing activity results in both components of nursing care
becoming de-skilled and routinized to focus on a legitimate subordinate group below
registered nurses. Whilst promoting flexibility the focus on HCA’s as a subordinate group has
the effect of maintaining occupational closure for registered nurses. Thornley (2007)
examines the flexibility which flows from skill mix and modernization in the context of
occupational closure strategies. Within these, flexible and across-boundary working, between
nurses and HCA’s has been presented as a self-proclaimed policy achievement, (see Saks and
Allsop, 2007). Whilst cross-boundary flexible working may operate HCA’s do however,
perceive themselves as substitutes for registered nurses and initially accepted this degradation
on the basis of promised progression opportunity and appropriate training opportunities to
secure progression. Moreover, Thornley argues that modernization and skill-mix strategies
secured de-skilling and routinization by cheapened nursing care. So whilst hospital managers,
ward managers and registered nurses each concentrate on what flexibility means to their
interests, these interests have displaced effective HR policies for job re-design, organizational
change and decision making. In turn the effects of this displacement mean that HCA’s can
experience flexibility as intensification (the encroachment of advanced tasks over routine
tasks), degradation (they are untrained) and de-skilling, (they are unqualified), (see
Cavendish, 2013:36-48, McBride and Mustchin, 2013).
Contradictory or Unforeseen Outcomes?
The conclusions presented by Thornley (2007) are further confirmed by Bach et.al. (2007)
who argue that HCA’s operate in a largely substitute supportive capacity defined by the wider
goals of public service delivery in particular cross party fiscal prudence and efforts to retain
recruited labour in the context of tighter labour cost budgets. Empirically, however,
registered nurses and HCA’s play out ill-defined blended but co-professional roles resulting
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in potentially contradictory outcomes for both groups, specifically the manner in which
HCA’s replace the auxiliary nurse role, (Bach et.al. 2008, 2012). Because the work of HCA’s
is poorly defined occupational boundaries and therefore efforts to secure occupational closure
by registered nurses in particular become blurred. Both registered nurses and HCA’s seek to
identify their specific contribution to health care and define its boundary. However, registered
nurses define HCA’s as helpers viewing the educational credentials they possess as marginal
so differentiating themselves from HCA’s in terms of technical competence and a distancing
from de-skilled delegated ‘dirty work’. In contrast to this, HCA’s view themselves as
providing hands-on care and emotional support for patients stressing the similarity of their
contribution to that of registered nurses. Blended outcomes are contingent on local contexts
and these situations prevail because of the absence of a clearly defined workplace role for
HCA’s, in turn this absence impedes more strategic efforts at job re-design across the health
service. Kessler et. al. (2013) report that changes in the role of registered nurses has created a
space for HCA’s. However, the absence of a clearly defined job role for HCA’s in the skillmix modernization agenda creates the potential for overlapping HCA typologies ranging
from ‘bedside technician’, ancillary, citizen, all-rounder to expert. More significantly the
study found that HCA’s who occupied citizen and all-rounder roles possessed high levels of
personal confidence in their role and abilities, that is were comfortable in performing
advanced tasks. In contrast to this it is likely that HCA’s who occupy other three typologies
demonstrate experience and capability but are unlikely to go beyond routine tasks. Hence the
key issue in defining the role of a HCA is human agency in a wider pattern of structured
antagonism and the manner in which this interacts with organizational structures. Kessler, et.
al.( 2012) takes this analysis further to demonstrate that any strategic underpinning in the
utilization of HCA’s varies across trusts leading to a variety of outcomes for stakeholders
including HCA’s themselves. A key argument developed by these authors is the absence of
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sustained strategic thinking in the utilization of HCA’s which in turn leads to significant
variations in the role of HCA’s and the work they undertake, training for it and resourcing of
the role.
2, Research Questions - How Do HCA’s Experience NHS Modernization?
The literature review revealed three broad summative issues which inform the research
questions asked by this study. Firstly, HCA’s experience of NHS modernization where the
frontier of control has moved decisively in favour of management. Secondly, the absence of
national standards for HCA’s stimulates the creation of locally contingent approaches which
provide organizational context to informal workplace control regimes. Thirdly, the attitudes
and behaviours of HCA’s towards absence and job satisfaction stimulate resistance strategies
or a ‘structured antagonism’ below the more abstract diffusion of NHS modernization.
2.1 Modernization and Management:
The deployment of HCA’s and any strategic underpinning related to this is very variable.
This results in a variety of issues and consequences for patient care, cost effectiveness and
HCA’s too. Specifically, whilst HCA’s are a distinct group of other, that is, are different to
qualified staff, different models of HCA practice across the routine and advance task
boundary are in evidence. These outcomes are the (un)-intended and contradictory
consequences of modernization and flexibility, (see Kessler, Heron and Dopson, 2012) and
are likely to reflect an incomplete frontier of control where resistance is mobilized in a
variety of ways. Hence the first component of the core research question on HCA’s
experience of modernization centres on how do HCA’s experience modernization where the
frontier of control has moved decisively in favour of management?
2.2 A Locally Contingent Workplace Control Regime
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The contradictions and consequences flowing from modernization are now significant issues
because the ‘regulatory space’ which modernization and skill mix strategies occupy has been
encroached upon informally by management fiat rather than being effectively grounded by
HR initiatives in terms of national standards for job re-design. That is, the frontier of control
has moved decisively in favour of management but in locally contingent approaches to HCA
deployment and management, (see Bolton, 2005, McBride and Mustchin, 2003, Cavendish,
2013 and Francis, 2013). Here the structure of work systems and management ideas imported
from the private sector require consistent quality of service delivery in formal structures.
Locally, in NHS trusts and within these at ward level, agency exercised by HCA’s confronts
modernization and associated informal structures. Hence, a second component to the core
research question centres on how do locally contingent approaches to HCA’s and equally
contingent resistance strategies provide organizational context to workplace control regimes?
This is particularly important in this case because the locally contingent mode of control is
responsible for re-allocating distributive gains from HCA’s to registered nurses. For a
broader discussion of the relationship between modes of control and allocation of
distributive gains see, Belanger and Edwards, (2013:437).
2.3 Local Resistance:? Absence and Job Satisfaction
Even though the frontier of control has moved in favour of management in hospital trusts and
on wards at TUH the simultaneous use of absence and presence of job satisfaction express
both conflict and a re-structuring of antagonism in the HCA labour process, (see Taylor,
et.al, 2010, Belanger and Edwards, 2013). At TUH a failure to ground regulatory space by
formal and standardized management initiatives reinforces the indeterminate nature of
management control in modernization where ‘being short staffed’ and the resultant effects of
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this appear to represent the substance of management control strategies. Hence, a third
component of the core research question centres on are absence and job satisfaction
understood as resistance strategies which structure antagonism within NHS modernization?
It is however, one thing to identify consequences as contradictory and un-intended it is
another to subject them to detailed empirical evaluation, (McGovern (2014:31). Accordingly,
part three provides detailed empirical evaluation of how HCA’s express conflict at TUH.
3. Research Methods and Empirical Findings
Contributions to the labour process debate and labour process theory subject abstract changes
in capitalist political economy to interrogation in workplace studies by examining the effects
of these changes on work systems and strategies and practices of managers and workers in
the employment relationship. In this case it can be seen that NHS modernization is focussed
on making NHS hospitals more flexible, modern and private sector like for patients by
cheapening the costs of nursing care and re-allocating these distributive gains internally. The
study provides a credible account of the manner in which HCA’s experience workplace
modernization in three ways. First, through interviews with HCA’s, second, by observing
HCA’s at work and in their relations with nurses and managers and third by reference to
policy and review documents on the role of HCA’s. The research examines the aspirations
and frustrations of HCA’s at work under modernization at TUH measuring these experiences
qualitatively in a locally contingent control regime where absence and job satisfaction
structure workplace conflict.
3.1 TUH
TUH is a large teaching and university affiliated hospital trust and employs nearly 8,000
people over two large sites. The hospital has over 1,000 in-patient beds, 30 operating theatres
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and a 100+ bed critical care unit and is recognised as one of Europe’s leading hospitals with
an international reputation for care quality, informatics and clinical training and development.
TUH was one of the first hospitals to secure NHS foundation trust status in 2004 and
currently treats over 90,000 in-patients a year. Despite its profile TUH was in 2013 one of
thirteen hospitals named by Dr. Foster Intelligence (HSJ, 2013) with a greater than acceptable
mortality rate. To counter this the hospital now self-reports the absence of MRSA cases for
over a year, (anonymised hospital web-site). The hospital has an in-house call bank for
HCA’s and in addition to this often calls in regular external agency staff. In-house bank
HCA’s either work very flexibly at short notice as a form of zero hours spot contracting or
permanent HCA’s do bank work as a form of over-time.
3.2 Research Methods
By using mixed methods the research combines primary and secondary research and builds
on a pilot study which revealed that absence rates for HCA’s are significantly greater than the
average absence rate for all non-medical hospital staff at TUH but that high absence rates did
not convert into quit rates. For this more substantive project the main research method was
sixty semi-structured interviews conducted with HCA’s supported by a structured
questionnaire completed by all interviewees. Interviews averaged sixty minutes in length but
some were as long as ninety minutes.
Thirty of the HCA’s at TUH are positioned on band
three (£16,110-£19,077) of the pay scale and the other thirty are on band two (£14,153£14,846) and the head of delivery confirmed that no HCA’s were remunerated on band four.
In comparison the minimum starting salary for registered nurses in 2012-2013 was £21,176
placing the minimum starting salary at the bottom of band 5, (RCN, 2012). Therefore in 2012
the minimum starting salary for a registered nurse was £2099 higher than the maximum HCA
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salary, excluding overtime payments. Table 1 compares key HCA statistics for TUH to the
national picture detailed in Cavendish, (2013:15)
Table 1. Key Statistics for Health Care Assistants
Cavendish Review
TUH Numbers
National Numbers
Average Age
45
38
Gender
84% Female
96% Female
Average years in Post
4.1 in England
6.1 (TUH is in England)
Pay
56% on Band 2
50% Band 2, 50% on Band 3
Interview transcripts were coded against the three research questions and findings were
further informed by material gathered in the structured questionnaire. The pilot study was
conducted in April 2012 and the main fieldwork interviews were undertaken in two batches
of thirty over three weeks in July 2012, that is, before the publication of the Cavendish
review. Whilst the main research method is qualitative, and bearing in mind that this is a
single site study, in some instances these findings are also presented numerically and
quantitatively in order to express the significance of particular issues to the HCA
constituency at TUH. In summary the research presents a theoretically informed single site
case study which has collected data through interviews, workplace observation, documents
and other material from the field site.
3.1 HCA’s under Modernization and Management?
All respondents both in interviews and in questionnaire transcripts defined themselves as
lower cost workplace substitutes for registered nurses and accepted their roles in the
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performance of work ranging from routine to advanced tasks. Many HCA’s did not however
accept that routine tasks such as rotation of patients, help with eating and drinking, washing
and bed sore control and wound dressing work were de-skilled merely because HCA’s
performed them rather than registered nurses. Many interviewees argued that whilst routine
and advanced tasks were subject to grade degradation this was not the same as de-skilling
because the routine tasks cited above and advanced tasks such as catheter maintenance could
not be de-skilled in terms of job content. Moreover, forty interviewees argued that this was an
inappropriate term to use because many registered nurses, that is, those theoretically more
skilled than HCA’s, ‘won’t because they can’t’ (HCA, 23) perform these tasks. HCA 23
added that this was part of the problem in how they (HCA’s) experience skill mix and
modernization. Twenty interviewees added that they experienced modernization as
‘managing’ the effects of managed labour shortages with a further fifteen interviewees
stating that they experience managed labour shortages as stress, for example, they report
feeling bullied, the carrier s of new about cancellation news or missed slot news and having
to run to get things done. The regular response reported across the sixty interviews was
‘nurses don’t help’. Variations on this statement were reported in forty-five of the sixty
structured questionnaire responses. So HCA’s as individuals and as a work group experience
modernization and skill-mix strategies at TUH as staff shortages, related workplace stress and
associated pressures from managers and registered nurses.
‘….. You spend a lot of time walking around pushing patients, this gets to be heavy work.
Sometimes schedules are so tight you are in effect running pushing a patient or running to get
a patient’ (HCA, 41)
‘…slots are missed and they don’t get seen or have to wait a long time so you feel you have
to get them there but you might not’ ( It’s not always like this but can be) (HCA, 23)
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The experiences of HCA’s as a work group demonstrate work intensification of routine tasks
at TUH resulting from faster patient turnover and greater use of day surgery year on year
without a corresponding increase in registered nurse numbers, (see also Bolton 2004:324).
The intensification of routine tasks has resulted in the delegation of more advanced tasks both
in absolute numbers and in more intensive repetition of routine tasks and some advanced
tasks to HCA’s who experience this as a subordinate group. More significantly intensive
repetition also acts as a form of workplace ‘learning by doing’. In addition to work
intensification HCA’s experienced modernization in other ways. First, staff shortages both
intensify work for those at work and are an indicator of stress as HCA’s react to work with
coping strategies such as calling in sick when they are not ill. Alternatively, genuine absence
results from overwork often in the form of back pain resulting from attempting to perform
tasks which really require two HCA’s. Second, absent colleagues create stress for those who
are at work. This is compounded because absence is not effectively managed at ward level.
Fifty-four interviewees stated that absence causes regular delays in outpatients and patient
care causing TUH to continually fall back on in-house bank staff or external agency staff. All
sixty interviewees stated that delays in patient treatment in outpatients and on wards could
easily be solved if managers and nurses stepped in to help out. Only thirty interviewees,
however, provided corroborative information to support their claims that they had
experienced managers and nurses declining to help them where HCA absence caused delays
in patient treatment, more often nurses or managers delegated instructions to HCA’s to do it
and leave something else. The depth of the evidence provided and the frequency with which
this response was recounted leaves little room to doubt the claims, however, the effects of
absence do create extra work for registered nurses. This often appeared to be one reason why
registered nurses declined to help as a matter of course. Occupational closure however
informal enables registered nurses to protect themselves from work intensification by
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demarcating routine and some advanced tasks as HCA work not theirs, that is, protecting
their distributive gains derived from a subordinate group. A third way in which HCA’s
experienced modernization and skill mix was the manner in which it made their role ‘just a
job’. Forty interviewees gave this response in two streams of response one which highlighted
limited pay and reward opportunities and a second related response which suggested that
promised learning and development opportunities were either limited or non-existent. At
TUH HCA’s argued that they couldn’t really get off grade 3 irrespective of their length of
experience, (nine HCA’s had more than ten years of experience in the job and four of these
had over twenty years of experience). Responses in fifty structured questionnaires highlighted
the relentlessness of the three ways in which HCA’s experience modernization and the
manner in which this gradually encouraged them to see their work as so routinized that it
became ‘just a job’. In contrast to feeling this all interviewees stated that they had entered the
job to help people and get on the nursing career ladder. Whilst a majority of HCA’s retain
intrinsic job satisfaction many saw a boundary between themselves and registered nurses
strictly enforced. HCA’s did however appear able to separate intrinsic job satisfaction from
the effects of the management control regime and the effects of their own absence on
colleagues and patients.
3.2 Local Workplace Controls
At TUH HCA’s experience modernization and skill mix as a highly localized boundary issue.
Intensification of routine and advanced tasks, delays to patient care and use of bank and
agency staff to solve delays and cope with absence appear as a locally contingent regime to
manage absence from work and its associated impact on the delivery of care. A focus on
these issues returned attention to the issue of managers and nurses not stepping in to alleviate
HCA staff shortages. In the findings from both interviews and questionnaire transcripts it
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proved difficult to find responses that cited or referred to specific TUH policies which
defined the boundary between the work of registered nurses and work which was delegated to
HCA’s. The absence of documentary evidence on this and the absence of denials from
additional interviews with the delivery team at TUH led safely ( in 2012) as it turns out to
the conclusion that the job roles of registered nurses and HCA’s had not been formally
defined or re-designed to any nationally defined standard. Alternatively, however, the head of
delivery confirmed that TUH had recently revised job descriptions for bands two and three
locally which included a guideline for delegation of tasks to HCA’s, (see also Cavendish,
2013:68). Questionnaire responses regularly recorded the claim that “They (nurses) just don’t
do that,” in references to activities which registered nurses won’t undertake. Many HCA’s
argued that registered nurses now effectively saw themselves as ‘schedulers’ and managers to
whom it didn’t matter if patient care was delayed because it created another ‘non-nursing’
nursing job for them to do which could be massaged and masked in any performance
management figures.
‘They (registered nurses) don’t really care about delays and absences it gives them the
opportunity to manage something else. They? (prompted) nurses and the delivery people are
like the railways they can always find a good defendable reason to explain why something
hasn’t been done. The hospital is primarily concerned with A & E targets not what goes on
with nurses and HCA’s’ (HCA 10)
This was one of the most revealing interview responses on the issue of boundaries and
closure. Fifteen interviewees stated that job satisfaction at work could be improved by the
presence of career incentives such as a career pathway and potential pay band improvement
to band four. Those who cited this response were distributed evenly across the sample and
were not confined to HCA’s who cited less than satisfactory or unsatisfactory job satisfaction.
Workplace frustration was evident both individually and collectively as a sectional work
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group response to the local control regime which centred on closure, demarcation and taskby-task delegation of routine and advanced tasks. Thirty-two interviewees stated that having
to manage staff shortages and related workload stress resulting from these shortages, that is,
others absence, was the reason for their own absence from work. Hence, as an individual
response HCA’s choose absence when they knew there was likely to be a ‘shift-shortage’ of
HCA’s, (this phrase was cited by numerous HCA’s). By choosing absence HCA’s avoided
further work intensification of routine and advanced tasks. HCA’s taking this course of action
were quite happy to admit that their absence intensified the work of their colleagues but
defended their position on the basis that it happened to all of them now and then. It follows
from this that absence creates ‘the script’ (HCA, 34) ‘we are short staffed’ whereas the
shortage of staff necessitates what Bolton (2004) terms managers ‘making it up’. Within this,
managing patient expectations involves ‘getting it across early’ (HCA 45) that a delay or a
cancellation is routine. When this doesn’t happen patients feel they have received good
service when really it was just a normal service and associated expectation. Only two
interviewees stated that lack of career progression prompted their absence. Thirty
interviewees stated that delays in patient care and cancellations could be avoided if managers
and nurses stepped in to help out. It seems more likely that managers and nurses don’t step in
for two reasons, one to protect their distributive gains and two because there is no point in
doing so if absences are such that they will lead to delays and or cancellations regardless.
Alternatively, managers appeared to focus on managing this process, for example, re-booking
etc. and assessing the impact on other apparently unrelated cases which are likely to be
‘bumped’.
One empirical limitation of this study is its exclusive focus on the views of HCA’s and the
manner in which they experience modernization. Because of this the reliability of some of the
claims made by HCA’s might be questioned. Under this heading and others however, the
19
frequency of critically focussed views from HCA’s which highlight the subordinate status
that they feel, suggests that the claims are reasonably reliable. Moreover, members of the
delivery team choose not to deny many of these points when clarification was sought on the
issue of occupational closure and job re-design. This point takes the analysis back to Daykin
and Clark’s (2000) assertion that modernization represented fordist state policy. The key
point is that fordism can only work if it is institutionalized formally at the workplace. Quite
evidently at TUH local managers failed to institutionalise modernization detailed in Agenda
for Change and the knowledge and skills framework. Alternatively they appear to have
chosen to establish HCA’s - a key component of modernization – informally by allowing
local regimes of closure and both routine and advanced task delegation. In turn they appear to
have accepted local responses to this in the form of absence as an individual or highly
sectional act of resistance to occupational closure and delegation by registered nurses. The
issue is further complicated in the relationship between HCA’s and registered nurses. This is
so because whilst there is clear evidence of what Edwards (1986:5) terms ‘structured
antagonism’ between HCA’s and TUH as their employer, this exploitation operates in two
modes. Firstly, in the mode of informal control exercised over HCA’s by registered nurses in
routine and advanced task-by-task delegation and secondly in the distribution of the ‘surplus’
created by this mode of control. That is, the cheapened cost of nursing care and price of
occupational closure exercised by registered nurses in their wage and status mark-ups over
HCA’s. In effect it is possible to see the mode of control and distribution of surplus as a form
on internal sub-contracting where on one level rigid demarcations are enforced by ward
managers and registered nurses as a form of occupational closure. Alternatively, but beyond
the view of HCA’s, absence and shortages create extra work for ward managers and
registered nurses. Their reaction to this appears to be selectivity in undertaking routine or
advanced tasks on the basis that if delays are inevitable they have to manage them and
20
therefore performing some routine or advanced tasks promptly may be of no value if
ultimately disruption has to be managed.
3.3 Absence and Job Satisfaction as Resistance?
At TUH modernization is experienced by HCA’s as alienation from more traditional auxiliary
nursing roles such as bedside care and related aspects of what was often termed ‘patient
involvement’ and a wider degradation of their workplace status. Herein a ‘sticky floor’
confines HCA’s due to limited opportunities and career development. Alienation was
manifest as having to act like registered nurses, that is, reducing or curtailing bedside
relationships with patients and relatives. This was not necessarily the case because HCA’s
wanted to do so but felt compelled to do so in order to get the job done particularly in respect
of advanced tasks. Alienation like this had a double effect; it demonstrated movement from
the HCA role as a ‘caring job’ to ‘a job with some caring elements’ but whilst some HCA’s
felt that they were compelled to act like registered nurses they recognized they had “no
chance” (HCA 5) of becoming one and some HCA’s felt the job was becoming more
degrading because of its dead-end status, (see also Wise 2007:478). HCA 5 added that TUH
had in the past (before all graduate status) put up to 20 of its best HCA’s into nursing
programmes annually but now this route had virtually closed down. These frustrations
encouraged HCA’s to cope by dis-engaging from caring at work – the ‘just a job’ response as
opposed to ‘this is a caring job’. In-effect the demands of the role compelled HCA’s to create
their own distributive gains which they sought out individually in the workplace, for
example, by ‘putting the “block-hole” on chat’ (HCA, 21) or making patients wait for
delivery of routine tasks where the imperative of advanced tasks dictated a priority.
Alternatively and in addition to this some HCA’s made these gains by strategic use of
absence. Protecting their own position appeared to make HCA’s increasingly instrumental in
21
the diffusion of an apparently contractual attitude where intrinsic job satisfaction and doing a
good job remained high priorities but within a framework which ‘unitized’ patients as
number 1, 2, 3 or 4 etc. A majority of the sixty HCA’s demonstrated good motivation in this
framework (low absence rates but a truncated commitment to patients as people) but others
were alienated and resorted to absence on a regular basis. HCA’s in both groups expressed
frustration under this line of questioning to argue that explaining absence or diagnosing why
things went wrong was not part of their job.
Interviews and questionnaires measured job satisfaction across a range of categories and
factors; individual HCA’s absence rates, propensity to quit, how HCA’s rated job satisfaction
and how job satisfaction had altered over the past couple of years. Overall, of the sixty
interviewees forty-five stated that their job satisfaction was satisfactory or better, nine stated
that job satisfaction was less than satisfactory but not unsatisfactory with six HCA’s stating
that job satisfaction was unsatisfactory. The coping strategies used by this sub-group to
sustain intrinsic job satisfaction included being absent from the workplace, whereas longer
serving HCA’s reminding themselves that they had too many years in to consider quitting.
That is, the benefits of a comparatively good pension scheme etc. could not be given up. In
contrast to this less HCA’s with shorter service cited current economic conditions, so to
paraphrase Taylor et.al. (2010) at TUH HCA’s were not ‘too scared to go sick’ but used
sickness absence as a form of resistance to re-coup distributive gains against the work
intensification of routine and advanced tasks. Therein economic fear kept long service and
shorter service HCA’s in the job.
‘this job is not great but its pay and working terms are in the current economic climate pretty
good’ (HCA 14)
4, Discussion of Findings and Conclusions
22
The findings from this study reveal that HCA’s at TUH experience modernization
substantively but informally within a locally contingent workplace control regime where the
frontier of control has moved decisively in favour of management. The experience is informal
because of the absence of nationally agreed standards for routine and advanced task
delegation and associated levels of supervision. The experience is substantive due to the
manner in which modernization has intensified the work of HCA’s and stimulated a
structured antagonism between ward managers, registered nurses and HCA’s. Therein HCA’s
like registered nurses seek to make up distributive gains which de-skilling and grade
degradation impose on them. In these findings the study confirms those of broader studies
such as Kessler, Heron and Dobson, (2012) which demonstrate varieties of outcome for
HCA’s in the modernization process with a variety of consequences for stakeholders and
HCA’s too. At TUH much of this variety is imposed informally through differences in the
scale and scope of routine and advanced task delegation. What, however, is clear, both in
broader studies and this one is that HCA’s are subject to sustained pressure from senior staff
but experience low pay and low status and are not seen as professionals in the same manner
as physiotherapists and social workers. The research question asked by this study is how do
HCA’s experience modernization which is informal yet substantive and what are the
unforeseen consequences of modernization and its grounding in workplace flexibility at
TUH.? Therefore what this study adds to the stock of literature is an original
conceptualization of the consequences of a national failure to institutionalise modernization
formally in hospitals and on wards as workplaces. On the first aspect of the research question
both modernization as a process and within that, management as a function, require formal
occupation of the regulatory space which is created by the modernization process. An
absence of national standards for the regulation of HCA’s means that regulation of HCA’s at
TUH is locally contingent and less formal because of this. Contingency appears to be
23
particularly present in the relationship between HCA’s, registered nurses and ward managers
in respect of delegation of routine and advanced task. This is evident first in the manner in
which absence intensifies delegation of these tasks and second in the manner which
delegation of advanced tasks becomes problematic in respect of supervision and the potential
for HCA’s working beyond their competence. The empirical material from the case study
provides a contextualized approach which reveals information on employee agency captured
by interview and questionnaire data. These sources suggest that HCA’s are willing
participants in their informal regulation but that this informality demonstrates a failure of
structure which creates potential space for HCA’s to confront locally defined informal
structures. Agency of this type legitimizes resistance in the form of a more contractual
approach to work. So on the second aspect of the core research question under a locally
contingent mode of control antagonism between HCA’s, registered nurses and ward
managers is expressed in a use of absence but is structured in three ways. Firstly, as a
reaction to work intensification or what managers refer to as ‘managing shortages’. Secondly,
absence appears as a reaction to the further extraction of distributive gains and losses which
HCA’s self –receive in the form of intrinsic job satisfaction, for example, the squeezing of
time for hands-off nursing care. Thirdly, absence like the broader regulation of HCA’s at
TUH is tolerated but informally so because it does not formally threaten occupational closure
and associated distributional gains by registered nurses. Rather, the effects of absence have to
be managed in terms of its effects of service provision, that is, potential delays and
cancellations.
On the third aspect of the core research question on the work experience of HCA’s at TUH,
local resistance to the demands of managers does not manifest itself as a reaction to the
changing political economy of Britain’s capitalism. The lack of reference to union activity by
those interviewed and in questionnaire transcripts demonstrates the local focus of resistance.
24
Hence it would be stretching the analysis to see resistance in the form of absence and retained
intrinsic job satisfaction as a contradictory outcome of changes to the political economy of
British capitalism. More locally the demands of modernization have stimulated pressures for
greater management control, yet the frontier of control is incomplete due in the main to the
absence of national structures to formally manage the HCA role and guide local
contingencies.
In conclusion absence is tolerated by ward managers and registered nurses because it does not
threaten the managerial prerogative within the locally contingent regime of control. The use
of absence by HCA’s is a form of resistance to work intensification and the associated
demands of management where the frontier of workplace control appears to have moved
decisively in favour of management. In more abstract terms this latter point does reflect
contemporary changes in the political economy of British capitalism but is experienced by
HCA’s, as modernization, that is, all politics are local and HCA’s see these changes as the
demands of management. At the micro level HCA’s retain intrinsic job satisfaction by
marginalizing aspects of their role particularly hands-off patient care and therefore secure
distributive gains by imposing this loss on those they seek to help. At the macro level
intrinsic job satisfaction is retained by a change of mind set towards a more contractual
approach where as individuals HCA’s appear able to dissociate their use of absence from its
effects on patients and colleagues. In terms of un-constructed industrial relations HCA’s
retain intrinsic job satisfaction by separating this from the locally contingent regime of
control blaming their behaviour on this regime and its informal structures.
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